Hair Today, Gone Tomorrow The Secret World of Trichotillomania

Trichotillomania sounds like a spider that you might meet in an Amazon rainforest. In reality, it is a mental health disorder that is characterized by the compulsive urge to pull out one’s hair. Trichotillomania is Greek for “hair pulling madness.” It is estimated that between one and three percent of the population suffers from this terribly embarrassing disorder at some point during their lives. If we take the conservative estimate of one percent, that would mean that three million people in the United States have this disorder!

Trichotillomania is often misunderstood, so let us examine two anecdotes that can shed light on this disorder.

Devorah’s Story – Focused Pulling

Devorah was 10 years old when she once pulled out one of her hairs on her head for fun. She felt a sense of relief that was puzzling but enjoyable. She pulled out a few more until she had about 10 hairs on the table in front of her. A couple of days later, she got an urge to pull some more hairs and knew that unless she obeyed her urge she would not be able to get rid of the tension that was rising inside of her. So she pulled some more. This became a habit that she could not stop. She knew that the hair pulling was a bad idea, but the urge was so powerful, she felt unable to resist. Actually, the more she resisted, the stronger the urge would get!

Eventually, she developed a bald spot in the middle of her head. She became very adept at camouflaging her issue by combing her hair in such a way as to hide the bald spot. She could not hide it forever, and when she was 13 years old her mother noticed the growing bald spot. Devorah broke down to her mother in uncontrollable tears as she knew that she was destroying her hair with her own hands, but felt helpless in controlling her urges. Devorah’s mother had suspected for a while that something “was up,” since Devorah refused to go on roller coasters, which she used to love, stopped going swimming, which was once her passion, and refused to get her hair trimmed.

Devorah never told her mother, because she thought that no one else in the world had this “crazy” behavior and therefore no one would know how to deal with it. She was petrified that she would be stuck with this damaging behavior for the rest of her life.

Yaakov’s Story – Automatic Pulling

For as long as Yaakov could remember, whenever he was relaxing, his hands would seem to automatically go to his head, and he would start mindlessly pulling his hair. This would happen when he was reading a book, shmoozing with friends, sitting in the car, or relaxing in bed.

After a few years, a bald spot started developing in the middle of his head. This did not concern him that much, as his yarmulke covered it quite nicely. When he reached age 15, he needed to get an oversized yarmulke to cover his growing bald spot. He wasn’t as traumatized as Devorah, since he figured that if his bald spot got too big, he would just get a really short haircut. Nevertheless, he really did not want to have a really short haircut, and he wished he knew of a way to take control of his habit. Like Devorah, he was unaware that treatments exist for this disorder, so he never bothered to speak to anyone about it.

As these anecdotes illustrate, compulsive hair pulling can be a response to an obsessive urge (focused pulling) or an ingrained habit (automatic pulling). Let us now take a few moments to learn the basic facts about trichotillomania.

Basic Facts

Peak age of onset is 9 to 13. But it can start as early as one year old.

Devorah and Yaakov pulled head hair. However, many people with trichotillomania pull hair from their eyelashes, eyebrows, beard (for males), arms, or legs.

During a hair pulling “session” one can enter into a trance-like state and remove many hairs, one at a time.

Although focused pulling is often a response to anxiety or an emotional trigger, the help of a therapist is frequently needed to identify the trigger.

There can be periods of spontaneous remission only to have it return months or years later.

Hair pulling tends to be more common when one is dealing with a lot of stress.

Hair pulling is sometimes followed by rituals involving the pulled hair, such as chewing and eating the hair or rubbing the hair across the face. There can also be rituals leading up to the hair pulling, such as twirling the hair and searching for the “right” hair to pull.

Hair loss can sometimes be permanent. Like many physical issues, it differs from person to person. Some people who have pulled for only five years will have permanent hair loss, while other people who have pulled for 30 years will be able to grow back a full head of hair.

Very often, the biggest issue with trichotillomania is not the hair pulling itself. It is the shame and humiliation that are inevitably associated with the condition. Especially for women, the emotional effects of trichotillomania can be absolutely devastating. It is common for sufferers to engage in elaborate tricks to hide their hair loss. This includes hats, wigs, and headscarves. Some people will even wear needless eyeglasses if their trichotillomania has caused them to lose their eyebrows.

That is not to say that there are no health risks. Sometimes sufferers will eat the pulled hair, which can develop into a hair ball in their digestive tract, as the hair (which is indigestible) accumulates. This ball, called a trichobezoar, can block the flow of ingested food which can lead to serious medical complications. Surgery might be needed to remove the obstruction. Also, the constant hair pulling from the same spot on the scalp or skin can lead to skin abrasions and infections. In addition, the constant sliding of hair shafts between the teeth can cause the teeth to become grooved.

Treatment

As with all mental health disorders, the question is how exactly does one overcome trichotillomania? Let us divide this question into three parts: lifestyle changes, medication, and psychotherapy.

Lifestyle changes: There are some claims that certain diets can help people stop hair pulling. However, research has failed to find compelling evidence for these claims. Nevertheless, as with all mental health disorders, a healthy lifestyle (healthy eating, exercise, and sufficient sleep) can be a mood booster, helping build up the “emotional energy” one needs to overcome any mental health disorder.

Medication: There is a lot of research investigating if antidepressants help relieve the symptoms of trichotillomania. Presently, research indicates that some people respond well to medication. Unfortunately, not all people benefit from medication, and even those who do will often regress to their old habits when the medication is terminated, unless the medication is augmented with psychotherapy.

Psychotherapy: The type of psychotherapy that has been shown to work very well for trichotillomania is cognitive-behavioral therapy (CBT), especially a specific form of CBT called Habit Reversal Training (HRT). Many studies find that the combination of therapy and medication is especially effective.

Very often, the therapy must also include relaxation techniques, since many sufferers experience severe feelings of anxiety in their body as the urge to pull builds up. This may include strategies such as deep breathing, progressive muscle relaxation, and guided imagery. HRT often needs to be augmented with other therapeutic interventions that fall under the category of CBT (cognitive-behavioral therapy). Obviously, since many years of suffering with trichotillomania can lead to clinical levels of depression, the therapist might need to treat the depression as well. Basically, as with all therapy, the therapy needs to be custom-tailored to the client.

Trichotillomania can be a very tricky disorder to treat. It is imperative that when one seeks treatment for this disorder, it should be with a therapist who has experience in this area.

The bottom line is that if you have trichotillomania, do not assume that you have to suffer for the rest of your life. There are effective treatments. It might not be easy, but with perseverance, it is a mountain that can be climbed.

Rabbi Azriel Hauptman is director of Relief of Baltimore, a mental health referral service. Contact him at ahauptman@reliefhelp.org or at 410-448-8356. This article was reviewed by Shmuel Fischler, LCSW, of CBT Solutions of Baltimore who has a subspecialty in OCD and related disorders, including trichotillomania. Contact him at sfischler@cbtbaltimore.com or at 443-693-7228.